UNIVERSITY OF CHICAGO
VISITING MEDICAL STUDENT SENIOR ELECTIVE APPLICATION
924 E. 57th Street, BSLC - 104
Chicago, IL 60637-5416
(773) 834-3757 (Phone)
(773) 834-1920 (Fax)
visiting.pritzker@bsd.uchicago.edu
Note to applicants: A complete application does NOT guarantee acceptance or admission. Please do not make travel arrangements until
you have received eligibility confirmation from the Center for Global Health's program coordinator and the Pritzker School of Medicine.
SECTION 1 - TO BE COMPLETED BY STUDENT
Date of Application
Student Name (LAST Name, FIRST Name)
Citizenship
Date of Birth
Current Address with City/State/Zip Code
Current/Best Email Address
Best Phone (No dashes)
Country of Citizenship
Passport number
Country of Legal Residence
City and Country of Birth
Type of US Visa (if already obtained)
MUST BE COMPLETED:
I am a
year matriculated medical student in a
-year program at the
. Only students who have completed a
comprehensive third year educational program may apply for fourth year electives at the University of Chicago, which includes 3 months
of Internal Medicine, 3 months of Surgery, 2 months of Pediatrics, 1 month of Obstetrics and Gynecology, 1 month of Psychiatry, and 1
month of Family Medicine, but is not limited to the number of months stated above.
Please detail the amount of time you have completed both inpatient and outpatient experiences that would enable us to
determine your eligibility. This information must be completed on the application.
Clerkships
Medicine
Surgery
Ob/Gyn
Psychiatry
Pediatrics
Family Medicine
Inpatient
Outpatient
Total
Please use double digits (i.e. 01, 02 or 10, 11, 12)
weeks
weeks
weeks
weeks
weeks
weeks
weeks
weeks
weeks
weeks
weeks
weeks
weeks
weeks
weeks
weeks
weeks
weeks
Choices and alternatives for electives at the University of Chicago should be chosen from the courses listed on the web:
https://duke.bsd.uchicago.edu/PSOMCourseCatalog/ . A course number must be entered, not just the course name. Please
note that international medical students are only eligible for electives in their faculty sponsor’s department and that take
place at UCM, not NorthShore or other affiliated sites.
Number of Months Requested: 1 month
2 months
Note: Students are limited to one-month electives unless from Partner Institutions.
1st choice: Course Name #
Course #
Start & End Date
to
2nd choice: Course Name #
Course #
Start & End Date
to
Have you previously participated in elective course work at the University of Chicago? Yes
No
If Yes: Month
Year
Please explain why you are interested in enrolling in a Pritzker elective (should not exceed 1500 words):
SECTION 2 – UCHICAGO FACULTY SPONSOR INFORMATION
Faculty Sponsor Name (LAST Name, FIRST Name)
Department
Title
Current Address with City/State/Zip Code
Current/Best Email Address
Best Phone (No dashes)
SECTION 3 – ACADEMIC INFORMATION
Medical School Name
Address
Postal Code
City
State/Province
Country
Email Address
Telephone
GPA
Highest Year of Medical School Completed
Total Number of Years
Current Field of Study
City and Country of Birth
TOEFL Score (if applicable)
SECTION 4: - EMERGENCY CONTACT INFORMATION
Emergency Contact Name (LAST Name, FIRST Name)
Relationship to Student
Current Address with City/State/Zip Code
Current/Best Email Address
Best Phone (No dashes)
Alternate phone
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SECTION 5: - ADDITIONAL MATERIALS TO BE PROVIDED BY STUDENT
Student is required to produce the following items with the completed application, and will NOT be allowed to begin any rotations at the
University of Chicago without these:
(1) Proof of personal health/hospitalization coverage (copy of insurance card) in effect while visiting student is rotating at the
University of Chicago (in English). Please note that basic travel insurance without health coverage is insufficient. University
policy requires:
a. Medical benefits of at least $50,000 per accident or illness
b. Repatriation of remains in the amount of $7,500
c. Expenses associated with the medical evacuation of the exchange visitor to his or her home country in the
amount of $10,000
d. A deductible not to exceed $500 per accident or illness
Some examples of alternate health plans can be found at: http://www.isoa.org/compass_main.aspx
(2) Proof of current immunizations (SCHOOL CERTIFICATE OR LAB REPORT) attached (in English). Please see the
additional immunization form on the requirements for visiting medical students found on the CGH website:
cgh.uchicago.edu.
(3) Please see the “Visiting Medical Student Checklist” on the last page of this application for all additional required materials and
submit all materials at once.
Student’s Photo Required
SECTION 4 - TO BE COMPLETED BY APPROPRIATE OFFICIAL AT VISITING STUDENT'S MEDICAL SCHOOL
Please circle the correct response (YES or NO) and complete each question:
(1)
The medical student named above is in good standing at this institution, and
is authorized to take this elective for credit (must include school’s good standing letter).
(2)
The student has the following ranking as a clinical student in this school:
_____ Outstanding
Very Good
YES
NO
Average
(3)
Date upon which this student will be awarded his/her M.D. degree _____________Month ___________Year
(4)
The student has proof of HIPAA Compliance, or plans to undergo HIPAA training upon arrival to Pritzker.
YES
NO
(5)
The student will pay tuition at the home institution during the period indicated.
YES
NO
(6)
The student has completed a course of study on universal precautions.
YES
NO
(7)
The student needs an evaluation form submitted to his/her home institution after the elective.
YES
NO
Please fill out your contact information and sign below:
Name, and Address of School: ____________________________________________________________________________
______________________________________________________________________________________________________
Phone Number:_________________________________________________________________________________________
Email Contact:__________________________________________________________________________________________
Name of Dean or School Official: (please print)__________________________________________Date: ________________
Signed: _____________________________________________ Title: ___________________________________________
Official Seal of the Medical School must be affixed:
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SECTION 7: - FOR PRITZKER OFFICE USE ONLY
Date of Receipt:
__________________________________
Date Application Reviewed:
__________________________________
Date Application to Program:
__________________________________
Date Decision Received:
__________________________________
Date Student Notified:
__________________________________
When confirming arrangements with the student, please ask the student to check-in with the Visiting Student Coordinator in the Pritzker
School of Medicine, 5841 S. Maryland Avenue, MC 7109, Room O-131, Chicago, Illinois 60637.
Approved By:
___________________________________________________________________ _________________________
Signature
Date
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Visiting Medical Student Checklist
- To be completed by student Complete the following checklist and return the signed original with your application. Please do not send partially complete
applications. Incomplete applications will not be processed. Applications must be received sixteen weeks before the start of
your intended rotation.
Required Item
Completed Visiting Student Application
Immunization Documentation – all three pages required
Letter of Good Standing from your school
Proof of Personal Health Insurance
CV in English
Copy of Visa and Passport
Official Transcript in English
Proof of HIPAA Compliance (This can also be completed upon arrival at Pritzker)
Completed
I hereby attest that the above items are complete and represent the official documentation required for my candidacy as a visiting student
to the University of Chicago Pritzker School of Medicine.
___________________________________________________________________ _________________________
Signature of Student
Date
Next Steps and Further Communication
(All communication will be sent via email. Due to the large volume of applications that we receive, please do not call to check the status of
your visiting student application.)
 Confirming Receipt:
 Scheduling Decision:
 Additional Instruction:
 Departmental:
An email confirmation of receipt of your application will be sent to you upon receipt.
You will receive email confirmation of acceptance or denial.
If you are accepted, you will receive an email with further instructions about the rotation and
a brief orientation three to four days before you are scheduled to arrive.
You may also receive program-specific instructions via email in addition to communication
from the Pritzker School of Medicine.
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